The transition to power for a new government in BC provides the opportunity to set a new course that addresses both immediate and longstanding policy challenges. On the health care front, there is no shortage of pressing issues facing the new government. It is reassuring, however, that one of the foundational principles of the NDP and Green Confidence and Supply Agreement is to “fix the services people count on.” Specific to health care, the agreement includes shared commitments to:
- Promote and protect the public health care system;
- Increase the emphasis on preventative health initiatives and services;
- Develop a plan to implement an essential drugs program;
- Provide seniors with the right care at the right time to improve health and reduce costs in hospitals by investing in home care, increase residential care staffing to meet provincial guidelines and establish clear staffing standards;
- Expand the use of multidisciplinary health care teams; and
- Develop and implement a Mental Health and Addiction Strategy and a Youth Mental Health Strategy while also ensuring there is sufficient funding for frontline services and there is an immediate response to the fentanyl crisis.
The need for these policies is clear—as documented in many CCPA-BC reports. Under-investment in community health care in particular has taken a great toll.
BC’s new government has the opportunity to foster a culture of teamwork, innovation and quality improvement in health care. Priorities should focus on reducing surgical wait times and improving the availability and integration of mental health and addictions services, seniors’ care and primary care and social services. But progress in these areas will also require bold action to address the affordable housing crisis. Addressing the ‘upstream’ social determinants of health—including income, housing and employment—cannot be ignored, otherwise the ‘downstream’ health and social services will simply be a band-aid solution. Health care services can only do so much when people are homeless. On this issue, the speedy $100 increase in social assistance is a step in the right direction—and hopefully part of a broader poverty reduction strategy.
In what follows, I identify key health care actions for the new government:
1. Reduce surgical wait times
In our 2016 CCPA-BC report, Marcy Cohen, Dr. Margaret McGregor and I provided detailed policy recommendations to reduce surgical wait times based on the international research evidence and best practices from BC as well as Scotland—a global leader in wait time solutions. Scotland’s approach is rooted in team-based care, continuous improvement and public delivery—all elements that should be part of BC’s strategy. The provincial government and health authorities will need to move away from using for-profit surgical clinics and, instead, improve surgical capacity in the public system over the long term—a direction that is supported by the research evidence. As well, the government needs to crack down on private clinics charging vulnerable patients illegal fees. Stopping these predatory practices will protect patients and reduce waits for everyone.
The health minister’s first orders of business could include firmly closing the door on the possibility of creating for-profit hospitals in BC and, instead, properly resourcing existing public operating rooms and extending the hours in order to work down the backlog and get ‘long waiters’ into surgery. Using public multidisciplinary pre-surgical assessment clinics is another strategy that can reduce wait times and discourage the inappropriate use of surgery when non-operative therapies may be more appropriate. When health care professionals, including physiotherapists, work in multidisciplinary teams and are supported to work to their full scope of practice, it can free surgeons’ time to perform additional surgeries and consult with patients who have the most urgent and acute need.
BC already has a successful model that could be scaled-up and expanded across surgical speciality areas. Vancouver Coastal Health’s Osteoarthritis Service Integration System (OASIS) is an innovative program that provides a single-point of contact for patients who may need orthopaedic surgery. The program reduces waits by quickly assessing patients by a multidisciplinary team for surgery, non-surgical therapies or self-management. It has the potential to substantially reduce waitlists for common surgeries (e.g. hip and knee). Fully utilizing public sector capacity and using multidisciplinary teams are just two elements of a comprehensive wait time solutions framework outlined in our 2016 paper.
2. Provide more appropriate and cost-effective care in homes and communities
A well-resourced and integrated home and community care system can help everyone—especially seniors and individuals with mental health and addiction challenges—stay healthy and out of hospital. We know that inappropriate use of hospital services and overcrowding continue to be significant challenges in BC. In fact, hospital occupancy rates are frequently at or over 100 per cent in every health authority, which is why patients are too often treated in hallways.
When community-based services are not available or are poorly coordinated, patients often end up in the hospital in a time of crisis because the necessary preventative care and supports were not in place. And because home and community care is not universally covered under the Canada Health Act like physician and hospital care, these critical services are not always available to meet the needs.
One way to spot shortfalls in access to home and community care is to look at hospital occupancy rates and patients who no longer require inpatient care but who continue to occupy a hospital bed because appropriate health care services in their home or community are not available. These are “Alternate Level of Care” or ALC patients and are often derogatorily referred to as “bed blockers.” The ALC issue is one of the biggest challenges to reducing wait times across the health care system. In 2015/16, ALC use (measured as “ALC days”) accounted for 13 per cent of total hospital use, and 84 per cent of ALC days involve seniors.1 The majority of ALC use (53 per cent) is related to mental health issues, dementia, rehabilitation, convalescence or palliative care.2
Improving access to will contribute to the most effective use of our public health care resources and reduces pressure on hospital and emergency services—the most expensive parts of the system. Based on what the ALC numbers tell us, the BC government should focus on seniors’ care and mental health care:
- Improve access to seniors’ home and community care. As I recommended in my recent seniors’ care report, developing a strong home and community care framework and action plan would be the ideal place for a new government to start. Today, publicly funded seniors’ home and community care services (e.g. home support, professional home care including rehab and nursing, assisted living and residential care) are less available than in 2001. This stems from privatization and underfunding. Public dollars are increasingly flowing into the pockets of for-profit corporations and investors rather than into frontline care provided by non-profit organizations and health authorities. The BC government should develop a coherent seniors’ care framework and action plan to increase access and address each community’s unmet needs.
- Improve access to community mental health and addictions care. Half of lifetime mental health and addictions challenges begin early in life—and 75 per cent of all mental illness will present by the age of 25. Hence the need for a youth mental health plan. Without proper care and supports, these illnesses can lead to addiction, homelessness and poor health. Mental health and addictions services that respect the rights of individuals and provide help before, and after, crisis cannot keep up with demand. This needs to change. BC already has successful evidence-based models that could be implemented province-wide. Foundry centres provide youth with a single point of access to peer support and a full range of mental health, addictions and primary health care and social services provided by a multidisciplinary team. This multidisciplinary community health centre model should be expanded province-wide to serve all age groups with the early intervention-focus that will keep people out of hospital and support long-term recovery.
3. Address health human resources challenges
Reducing wait times and expanding access to publicly funded home and community care will require a commitment to health human resources (HHR) planning. Real leadership on the HHR planning file has been neglected for too long, and as a result, there are critical shortages of frontline staff across the system. Failure to recruit and retain sonographers, for example, is leading to longer wait times. Heavy workload, high rates of workplace injury and violence, and the high cost of living all contribute to the HHR challenges in BC. Plans for increased staffing in seniors’ residential care is critically necessary but there are other areas, too, that require urgent attention. We also know that expanding for-profit health care delivery, including private surgical clinics, pulls critical staff out of the public sector, making the problem worse. Phasing out for-profit health care service delivery would go a long way in helping address long wait times and workforce challenges in our province.
But for this work to be effective, it should be guided by the following principles that are at the root of social and health care policy innovation:
- Focus on quality improvement with expected outcomes. Our public health care system has suffered from a lack of provincial leadership to drive health care system improvement and scale-up innovative practices province-wide. In BC, there are numerous examples of local pilot projects—led by local champions—that have made better use of existing resources while also improving the quality of care. These pilots could become standard practice across our province, but they need provincial-level coordination and support. Robust data collection, reporting and continuous program evaluation must inform quality improvement efforts.In BC there has so often been a disconnect between the Ministry of Health, regional health authorities and frontline providers. Leadership means dedicated Ministry of Health resources to drive quality improvement. For example, the government could establish a “Surgical Excellence Secretariat” in the Ministry of Health that would be responsible for coordinating health authority “improvement teams” and efforts to support local health care providers implementing improvement. Leadership also means the expectation of outcomes. The Ministry needs to set reasonable targets that help health authorities achieve success. Quality improvement must be an ongoing process that is driven by reliable data, the expectation of results and a culture of learning and collaboration.
- Sustained improvement will require collaboration, teamwork and democracy. Improving the public health care system will require a commitment to create new inclusive spaces and structures for discussion, collaboration and learning between patients, frontline workers, bureaucrats, policymakers and civil society groups. Everyone must be involved—especially patients and communities—in how services and programs are designed and delivered. Public services must be attentive to the needs of citizens and accountable to the communities they serve.
- Policy decisions should be based on the research evidence with a focus on reducing health inequalities. Applying a health inequalities ‘lens’ to policy decisions considers how the social determinants of health—income, employment status, race/ethnicity, housing situation, etc.—significantly shape physical and mental health. There is a clear relationship between ‘high users’ of hospital care, often with chronic conditions, and poverty.Policy decisions should be evaluated based on whether they are likely to reduce or increase health inequalities in society. The evidence demonstrates clear links between neoliberal or market-oriented policies and rising health inequalities. Privatization fragments health and social services, erodes working conditions for frontline workers and moves us closer to a US-style system.
- Integrate health care, social services and supportive housing. Integration is a requisite if the provincial government hopes to reduce health inequalities and improve the quality and efficiency of services. The BC government should consider new structures for cross-sectoral collaboration that will start laying the foundation for health care, social services, child care and supportive housing integration. Jobs in health care and social services are foundational to our provincial economy, representing the second-largest share of employment (12 per cent). The new BC government should consider how it can nurture and better integrate these sectors as part of a broader jobs and innovation agenda.
The new provincial government faces no shortage of pressing issues, but with commitment and a collaborative approach to policy change, BC can become a global leader in progressive health and social care reform.
- Andrew Longhurst (2017), Privatization and Declining Access to BC Seniors’ Care: An Urgent Call for Policy Change, Vancouver: Canadian Centre for Policy Alternatives—BC Office, p. 10.
- BC Ministry of Health (2017), “Hospital Workload by Governance Authority,” HealthIdeas, reported generated July 6, 2017, at: http://public.healthideas.gov.bc.ca/portal/page/portal/HealthIdeas.